Like any surgical specialty, there are potential complications that trainees should be aware of. Three major complications in oculoplastic and orbital surgery
include retrobulbar hemorrhage, infection, and cerebrospinal fluid (CSF) leak.
This article describes these three complications in detail and how to avoid or remedy them for the best surgical outcomes.
Complication #1: Retrobulbar hemorrhage
is a rare but serious complication that can occur after orbital or eyelid surgery. Bleeding behind the globe, within the retrobulbar space, can lead to an orbital compartment syndrome.
This can cause pressure to build up within the confined space of the orbit, leading to decreased vision, proptosis, severe pain, and even optic nerve damage from compressive optic neuropathy. Patients who are on anticoagulant medications are at a higher risk for retrobulbar hemorrhage, and great care should be taken in these patients to manage their medications in the peri-operative period.
If retrobulbar hemorrhage occurs, immediate intervention is needed to relieve the pressure, control the bleeding, and prevent permanent damage to vision and the optic nerve. Certain oculoplastic surgical procedures have a higher risk due to their proximity to the orbit and the potential for disruption of blood vessels.
Some of these high-risk oculoplastic procedures include:
- Blepharoplasty: Lower eyelid blepharoplasty can pose a higher risk for retrobulbar hemorrhage due to the manipulation of orbital tissues and fat, which can inadvertently damage blood vessels.
- In rarer cases, upper eyelid blepharoplasty can also lead to orbital hemorrhage if the medial fat pad is disrupted. Blood vessels within the orbital fat can hemorrhage if meticulous hemostasis is not achieved.
- Orbital decompression surgery: This surgery is performed to alleviate proptosis and compressive optic neuropathy in conditions like thyroid eye disease (Graves' disease). It involves removing or reshaping portions of the orbital bones to create more space for the eye.
- Orbital fracture repair: Repair of fractures involving the orbital bones may necessitate oculoplastic surgery. Manipulation and fixation of fractured bones in the periorbital area can increase the risk of bleeding into the orbit, potentially leading to retrobulbar hemorrhage.
- Dacryocystorhinostomy (DCR): While the primary focus of this surgery is the tear drainage system, it can involve manipulation of tissues near the orbit and medial canthus. Careful surgical technique is necessary to minimize the risk of complications, including retrobulbar hemorrhage.
Precautionary measures to prevent retrobulbar hemorrhage
Preventing retrobulbar hemorrhage during oculoplastic surgery involves careful surgical technique, meticulous hemostasis, and being prepared to respond promptly should bleeding occur.
Here are eight precautionary measures and steps to minimize the risk of retrobulbar hemorrhage during these procedures:
- Patient assessment: Be aware of the patient's medical history and any medications that may increase bleeding risk (e.g., anticoagulants). Ensure the patient's blood pressure is well-controlled before surgery, as high blood pressure can increase the risk of bleeding.
- Surgical planning: Take into consideration the anatomy of the orbit and surrounding structures. Have a clear surgical plan and consider alternatives to high-risk procedures when appropriate.
- Hemostasis: Achieve and maintain meticulous hemostasis throughout the procedure. Use bipolar cautery, hemostatic agents, or sutures as needed to control bleeding from small vessels.
- Gentle tissue handling: Handle tissues around the orbit gently to minimize trauma to blood vessels.
- Minimize tissue dissection: Limit dissection in areas with a higher risk of retrobulbar hemorrhage, such as the orbital floor or near the optic nerve.
- Use of vasoconstrictors: The use of vasoconstrictors like epinephrine in local anesthetic solutions helps constrict blood vessels and reduce bleeding.
- Intra-operative monitoring: Sudden increases in intraocular pressure (IOP) or signs of orbital congestion may indicate impending retrobulbar hemorrhage.
- Know the signs: Familiarize yourself with the early signs and symptoms of retrobulbar hemorrhage, such as sudden proptosis, decreased vision, and increased IOP.
Management techniques for retrobulbar hemorrhage
If retrobulbar hemorrhage occurs or is suspected, it's essential to act quickly. Release any surgical tension and use surgical instruments judiciously to expose the source of bleeding.
If a bleeding vessel is located within the orbital soft tissues or fat, clamping and cauterizing the vessel swiftly can stop the hemorrhage. Conversely, if the source is located in the orbital bones during orbital decompression
or fracture repair, applying bone wax locally with a cotton tip applicator is helpful.
In severe cases, emergent decompression may be necessary. This can involve lateral canthotomy and cantholysis
, needle aspiration of blood from the orbit, or surgical exploration to locate and control the source of bleeding. Ensure effective communication with the surgical team, anesthesia team, and nursing staff to facilitate a coordinated response in case of complications.
Post-operative monitoring is equally critical. After surgery, closely monitor the patient for signs of post-operative retrobulbar hemorrhage. Patients should be informed about signs of increased orbital pressure pain and decreased vision, and instructed to seek immediate medical attention if they occur.
Complication #2: Infection
Infection is a common complication in any surgical procedure. Infections can occur in the eyelids or orbit, leading to complications such as wound breakdown, cellulitis, abscess formation, and even sepsis in severe cases.
Patients who are immunocompromised or diabetic
may face higher risks for post-operative infection. Community-acquired methicillin-resistant Staphylococcus aureus
(CA-MRSA) is particularly on the rise in certain areas and may cause post-operative soft tissue infections.
Precautionary measures to prevent infection
Several infection-prevention strategies are key to reducing the oculoplastic surgery complication rates.
Important steps for avoiding infections in oculoplastic surgery include:
- Strict aseptic technique: Ensure that all surgical instruments, drapes, and equipment are properly sterilized pre-operatively. Be alert during the procedure and maintain a sterile field throughout the case.
- Antibiotics: Consider prophylactic antibiotics, particularly if the patient is immunocompromised at baseline or has implantable devices. Prescribe post-operative topical and/or oral antibiotics for patients to take during the recovery period.
- Hand hygiene: Pre-operative hand washing with antiseptic soap, along with the use of gloves and sterile gowns, is essential.
- Pre-operative surgical preparation: Ensure that the surgical site is prepared with betadine solution before draping. This reduces the microbial load on the patient's skin.
- Post-operative wound care: Provide written instructions to patients on post-operative wound care. Reinforce the importance of not touching the surgical site and avoiding any form of contamination.
- Early detection of infection signs: Teach patients to recognize signs of infection, such as increased redness, swelling, purulent discharge, or elevated temperature. Encourage them to call your office with any abnormalities promptly.
- Immunization: Encourage your surgical patients to stay up-to-date with immunizations, particularly influenza and pneumococcal vaccines, as these can help bolster their immune defenses during the vulnerable post-operative period.
- Continued surveillance: Track surgical site infections. This includes monitoring and reporting rates, identifying trends, and implementing corrective actions when necessary.
Management techniques for infection
Depending on infection severity, management typically involves a combination of medical and surgical interventions.
Key measures for addressing infections in oculoplastic surgery include:
- Cultures and sensitivity testing: Obtain wound cultures and sensitivity testing to identify the causative organism and determine the appropriate antibiotic treatment.
- Broad-spectrum antibiotics: Initiate empiric broad-spectrum antibiotic therapy while awaiting culture results. The choice of antibiotics should be based on local antibiograms and the patient's clinical condition.
- Surgical debridement: If there is localized purulence or an abscess, consider surgical drainage and debridement of the infected area. This helps remove infected tissue and facilitates better penetration of antibiotics.
- Antibiotic adjustment: Adjust antibiotic therapy based on culture and sensitivity results.
- Intravenous (IV) antibiotics: Administer IV antibiotics when the infection is severe, rapidly progressing, or when oral intake is compromised.
- Wound care: Clean the surgical site with an antiseptic solution and change dressings as needed, maintaining sterility to prevent further contamination.
- Systemic support: Address pain control, hydration, and fever reduction, as needed.
- Close monitoring: Continuously monitor the patient's clinical condition, paying attention to vital signs, laboratory values, and local wound appearance. Adjust treatment as necessary based on the patient's response.
- Consultation with infectious disease: Consider involving an infectious disease specialist, especially in cases of orbital cellulitis, for optimal antibiotic guidance.
- Patient education: Educate the patient about the importance of compliance with antibiotic therapy, wound care, and follow-up appointments.
Complication #3: Cerebrospinal fluid leak
A CSF leak
is an uncommon but potentially serious complication that can occur, particularly in surgeries involving the orbit or ethmoid sinus area. It arises when there's an unintended breach in the dura mater, the protective covering of the brain and spinal cord, leading to the leakage of cerebrospinal fluid.
Higher-risk surgeries where CSF leak could occur include orbital decompression and dacryocystorhinostomy. CSF leak can result in headaches, clear watery discharge from the nose (rhinorrhea), and, in severe cases, an increased risk of infection in the brain.
Detection and repair of CSF leaks are essential to prevent complications, and immediate consultation with neurosurgery may be required.
Precautionary measures to avoid CSF leaks
Preventing CSF leaks during orbital surgery requires a combination of careful pre-operative planning, precise surgical technique, and vigilance during and after the procedure.
Taking the following precautions can help avoid CSF leaks:
- Thorough pre-operative assessment: Perform a comprehensive pre-operative evaluation—including a detailed medical history—to identify any risk factors for CSF leakage, such as prior sinus surgery, intracranial hypertension, or known anatomical anomalies.
- Imaging studies: Pre-operative imaging, such as computerized tomography (CT) of the orbits for surgical planning, is critical to evaluate the anatomy of the orbit, sinuses, and skull base. This can help identify any potential anatomical variations or abnormalities that might increase the risk of CSF leak.
- Surgical planning: Develop a detailed surgical plan, considering alternative techniques that avoid areas with a higher risk of CSF leakage.
- Intra-operative navigation: Use intra-operative neuro-navigation systems to precisely locate and avoid critical structures, including the skull base and cribriform plate, where CSF leaks are more likely to occur.
- Navigated orbital surgery allows for real-time three-dimensional (3D) localization of surgical instruments and bony landmarks within the orbital space. This allows the surgeon to gauge intra-operative proximity to the brain better and helps avoid complications that may otherwise arise from poor intra-operative visualization.
- Gentle tissue handling: Handle tissues with care to minimize trauma and prevent inadvertent breaches of the dura mater or skull base. Avoid excessive manipulation of tissues near the ethmoid sinuses and frontal sinus.
- Use of barrier materials: Consider the use of barrier materials or grafts to reinforce potential areas of weakness or to seal off regions where CSF leakage might occur. Materials like collagen matrix, fat grafts, or other biological tissues can be used as barriers.
- Hemostasis: Achieve meticulous hemostasis throughout the surgery to minimize the need for excessive tissue manipulation, which can increase the risk of dural breaches.
- Post-operative care: After surgery, closely monitor the patient for signs of CSF leak, such as clear watery discharge from the nose (rhinorrhea). Educate the patient about these signs and instruct them to report any unusual symptoms promptly.
Management techniques for CSF
If a CSF leak does occur, immediate recognition and management are key to ensuring surgical success and minimizing post-operative issues.
Some general steps to CSF leak management include:
- Immediate recognition: Clear fluid drainage is highly suggestive of CSF. If you suspect a CSF leak during orbital surgery, stop the surgery immediately.
- Inform the team: Communicate with anesthesia and nursing staff about the suspected CSF leak. It's crucial that everyone is aware of the situation and prepared to assist.
- Positioning: Elevate the patient's head to minimize the gravitational pressure on the CSF leak. The patient should be in a head-up position to help reduce CSF drainage.
- Dural repair: The primary goal is to repair the dural defect to stop the CSF leak. Defects can be patched with grafts, such as autologous tissue (e.g., fascia or fat) or synthetic materials.
- Ensure secure placement and sealing of the graft to prevent further leakage. In some cases, fibrin sealants or other tissue adhesives can be used to reinforce the dural repair and minimize the risk of recurrent leakage.
- Neurosurgical consultation: Depending on the extent and complexity of the CSF leak, consider involving a neurosurgeon experienced in managing CSF leaks.
- Post-operative care: After repairing the CSF leak, closely monitor the patient in the post-operative period for signs of recurrence or complications. Maintain a head-up position to reduce CSF pressure.
- Radiological evaluation: Post-operative imaging, such as CT or magnetic resonance imaging (MRI) scans, may be necessary to confirm the resolution of the CSF leak and to evaluate the success of the repair.
Residents and fellows should also be aware of other potential complications, such as scarring, asymmetry, under-correction or over-correction of aesthetic issues, and damage to adjacent structures like the eye itself or the tear drainage system.
Close supervision and guidance from experienced mentors are crucial for developing the skills and judgment necessary to prevent, recognize, and manage these complications effectively.